When written in Chinese, the word ‘crisis’ is composed of two characters. One represents danger, and the other represents opportunity.1

Mrs. R, age 43, is agitated and confused, and her husband has brought her to the hospital’s emergency department. He reports that she has a history of denying alcohol abuse and told him during an argument yesterday that she could stop drinking any time she wanted to.

You are the psychiatrist on call. As the emergency medical team treats the apparent withdrawal episode, you tell Mrs. R’s husband: “We’ll take good care of your wife because alcohol withdrawal is dangerous and painful. But after detoxification, it’s important to prevent her from getting sick again. She needs to enter a rehabilitation program, and then outpatient treatment. When she comes around, maybe you could remind her about how much pain she was in and bring her to the rehab center yourself…”

Addicts face potentially life-threatening consequences from their behavior, which—when handled skillfully in the emergency room—can start them on the road to recovery. Some say the addict must “hit bottom” before making the changes necessary for a sober life. You can help the addict define his or her bottom as an unpleasant trip to the hospital—instead of death or loss of a job or spouse—by realistically assessing the physical consequences of continued drug or alcohol use (Table 1).

Emergencies related to alcohol or drug use accounted for 601,563 visits to U.S. emergency departments in 2000, according to the government-sponsored Drug Abuse Warning Network (DAWN).2 Alcohol in combination with any illegal or illicit drug accounted for 34% of emergency visits, cocaine for 29%, and heroin for 16%.

Mortality rates vary by region. In Los Angeles, for instance, heroin and cocaine each caused approximately the same number of deaths when compared with alcohol in combination (Figure).3 Most deaths (73%) were considered accidental/unexpected, with 19% coded as suicide. New York City showed similar percentages of deaths called accidental/unexpected, but heroin as the cause of death ran a distant fourth to cocaine alone, narcotic analgesics alone, and alcohol in combination.2

Addiction crises bring more than a half-million Americans to hospital emergency rooms each year (Box 1,Figure).2,3 This article describes teachable moments—suicide attempts, accidental overdose, intoxication, and withdrawal—that you can use to bundle acute treatment with referral for addiction treatment.

Suicide

Suicide is the addict’s most immediate life-threatening emergency. Psychiatric and addictive disorders often coexist,4 but some substances can trigger suicidal behavior even in the absence of another diagnosable psychiatric disorder. The addicted person who jumps off a roof, believing he can fly, may think perfectly clearly when not using crack cocaine.

Addiction to any substance greatly increases the risk for suicide. An alcohol-dependent person is 32 times more likely to commit suicide than the nonaddicted individual.5 And the suicidal addict often has the means to end his life when he feels most suicidal.

Diagnosing and treating suicidality require a high degree of vigilance for subtle clues of suicidal behavior. Because suicide risk has no pathognomonic signs, clinical judgment is required. Though addiction itself can be viewed as a slow form of suicide,6 signs that suggest an immediate threat to life include:

Some addicts feign suicidal thoughts or use them as a cry for help. Any mention or hint regarding suicide marks a severely disturbed patient who needs a complete psychiatric evaluation. This includes a formal mental status examination and exploring whether the patient has access to lethal means.

We cannot consistently predict our patients’ behavior, but a careful examination often reveals the seriousness of a suicidal threat, method, and intention, as well as support systems for keeping the patient safe. Consulting with a colleague can offer a “fresh look,” allowing two clinicians to balance the need for treatment against concerns such as bed availability and possible malingering.

Suicidal thoughts are unassailable grounds for comprehensive evaluation and treatment—regardless of the suicide evaluation’s outcome. The addict who even hints at suicide should undergo a thorough medical and psychiatric evaluation and then engage in whatever treatment is indicated.

Emphasize the seriousness of suicidal thoughts to the patient, his family, third-party payers, and whomever else has influence in bringing the patient to treatment. Suicidal behaviors or intentions remain one of the few legal justifications for involuntary hospitalization.

Accidental overdose

An accidental overdose provides another teachable moment to convince the addict to enter treatment. Patients who try to make a statement by overdosing on a substance they consider benign, such as oxycodone with acetaminophen, can inadvertently kill or badly injure themselves. Conversely, patients who clearly intend to harm themselves may misconstrue a substance’s lethality and ingest a large amount of a relatively nonlethal substance such as clonazepam. Either case:

is a true psychiatric emergency

bodes poorly for the patient’s future

provides a strong rationale for addiction treatment.

Whether the means or the intent were deadly or benign, the overdose can be used as a convincing argument for treatment.

Intoxication

Intoxication with any addictive substance impairs judgment and increases the danger of injury. Specific medical dangers include alcohol’s powerful CNS depression in the nontolerant individual and the possibility for heart attack and stroke in the cocaine-intoxicated patient.

Attempts to convince an intoxicated person of the need for addiction treatment are usually futile. But the acute treatment represents a golden opportunity to reach out to friends and family members, who often escort the intoxicated addict to the emergency room. A medical record documenting the patient’s impaired behavior serves as evidence for (later) convincing the addict to go into treatment or for legal coercion of that treatment.

Table 2

MANAGING SYMPTOMS OF ALCOHOL WITHDRAWAL AND DELIRIUM TREMENS

Alcohol withdrawal

Delirium tremens

Begins 4 hours to 2 days after cessation of alcohol or precipitous drop in blood alcohol level

Begins 1 to 2 days after cessation of alcohol or precipitous drop in blood alcohol level

Withdrawal, like intoxication, presents emergency conditions specific to the abused substance. Unlike the intoxicated patient, however, a patient experiencing the unpleasant symptoms of withdrawal may understand the need for addiction treatment. Because alcohol withdrawal often requires sedative/hypnotic treatment, the wise clinician can design a treatment plan that combines the anti-withdrawal medication with:

attending Alcoholics Anonymous meetings

taking disulfiram 12 hours after the last alcohol use and then daily

and participation in relapse prevention psychotherapy.

Emergency treatments

Psychiatrists often have close contact with addicted patients in the hospital, clinic, or emergency department and therefore need to be familiar with basic techniques for managing addiction emergencies. Although addiction-trained psychiatrists manage emergencies at many institutions, general psychiatrists who have learned the following guidelines can form quick and solid therapeutic alliances with their addicted patients in the emergency department.

Alcohol

People live dangerously when intoxicated; about 40% of fatal U.S. car accidents involve a drunken driver.9 Alcohol also can incite physical violence and self-damaging sexual behavior and cause respiratory depression and death.

Acute effects of alcohol intoxication must be treated while guarding against potentially lethal withdrawal. Dangerous intoxication states with respiratory compromise may require aggressive supportive care, including intubation and mechanical ventilation. For agitated, intoxicated persons who represent a threat to themselves or others, chemical sedation with benzodiazepines—as opposed to physical restraint—is the preferred treatment.

Alcohol withdrawal requires immediate, definitive treatment (Table 2). Although mild withdrawal is common among alcoholics who cut back on or abruptly stop drinking, it can devolve quickly into delirium tremens (DTs). Serious medical problems—including severe autonomic instability and seizures—occur with DTs, which are associated with mortality rates of 5 to 15%.10 The adroit emergency department clinician can use the alcohol withdrawal/delirium episode to encourage the patient to begin addiction treatment (Box 2).11

Cocaine

Stimulants—most commonly cocaine and smoked methamphetamine—can cause myocardial infarction, cardiac arrhythmia, cerebral hemorrhage, hyperpyrexia, and status epilepticus.12 These emergencies occurring in a young person indicate the need to screen for cocaine use. Because no antidote exists for stimulant intoxication, we can only deliver supportive care while remaining vigilant for other sequelae of stimulant use, such as agitation and hypertension.13

Opiates

Overdoses leading to coma and death are the most devastating physical consequence of opiate abuse. Contrary to popular belief, orally ingested and inhaled opiates can depress respiration enough to cause death, just as injected opiates can. Because even appropriately prescribed opioid medications can lead to overdose or addiction, emergency treaters should be prepared to refer patients for pain management.

High-potency heroin often causes overdose in the novice user or in the addict who is surprised by a sudden increase in the heroin’s purity. Adulterants used by dealers to “cut” heroin also can cause illness and death. Quinine, for instance, can cause cardiac arrhythmias. Contaminants such as fentanyl and cholinergic agents such as scopolamine added to enhance the “high” associated with heroin can increase the risk of toxicity or death.

To what level of care should you refer the addicted patient from the emergency department—an inpatient medical unit, psychiatric unit/detoxification facility, residential treatment, partial hospitalization, or other model of care? The American Society of Addiction Medicine (ASAM) manual lists disposition recommendations to match individual patients’ clinical criteria. The criteria and levels are listed here as reminders of the issues involved in referring the addicted patient.

The drug 3,4-methylenedioxymethamphetamine (MDMA)—also known as Ecstasy, X, and XTC3—provokes release of dopamine and serotonin into the synapse, causing a sense of blissful open-mindedness, closeness to others, and the ability to “break down (mental) barriers.”14 In the context of “rave” dance parties, MDMA also causes dehydration and hyperthermia, which can lead to rhabdomyolysis, kidney failure, and death.

Life-threatening consequences generally occur only when adequate water is unavailable to a group of intoxicated, dancing teenagers.15 The more common emergency presentations include sudden hypertension, tachycardia, vomiting, depersonalization, panic attacks, and psychosis.16

Immediate treatment includes restoration of normal fluid levels and body temperature, plus reassurance for the non-life-threatening, more common, presentations.

Phencyclidine

Phencyclidine (PCP) and its analogue ketamine—originally developed as anesthetic agents—are no longer used therapeutically because they can cause dissociation, anxiety, and even psychosis. Panic can change to hyperactive behavior, aggressiveness, and violent acts, so the first treatment goal must be to secure the safety of the intoxicated person and others. Chemical restraints such as benzodiazepines are preferred to physical restraints, although some situations may require physical restraint, at least initially.17

Mr. G, age 73, visits your office reporting poor sleep, fatigue, and loss of appetite. His son says that Mr. G has been forgetful lately and has called to ask how to perform routine tasks or how to get to stores he often visits. Mr. G takes citalopram, 40 mg/d, for depression and atenolol, 50 mg/d, for high blood pressure. How would you begin to assess Mr. G’s symptoms?